National Association of State Mental Health Program Directors'
Housing Experts Workshop
November 20 - 21, 1995
Sponsored by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration
Executive Summary
Introduction
I. Planning
II. Financing Strategies/Partnerships
III. Development and Management
IV. Rental Assistance Strategies
V. Housing and Market Preferences
VI. Managed Care: The Impact on Housing and Supports
VII. Access to Supports
VIII. Rights
References
Appendix A. NASMHPD Position Statement on Housing
Appendix B. NASMHPD State of the States Housing Survey Results
Appendix C. For More Information
[Appendices not included here]
Introduction
The National Association of State Mental Health Program Directors (NASMHPD) and the Center for Mental Health Services (CMHS) of the Substance Abuse and Mental Health Services Administration (SAMHSA) have a long history of supporting housing initiatives on behalf of persons with serious mentalillness. The Housing and Support Position Statement adopted by NASMHPD in 1987 provided the leadership and legitimacy needed in many states for the development of housing initiatives. More recently, NASMHPD and CMHS convened a focus group on housing for persons with mental illness (March, 1995). The meeting helped determine national information needs, and one result was the NASMHPD State of the States Housing Survey. Focus group members were concerned that the importance of housing in public systems had been eclipsed by the changing environment. This concern was somewhat relieved by the overwhelming response to the survey - 47 state mental health authorities responded with information!
The survey clearly indicates a high level of interest in housing and supports despite the changing environment. An interesting portion of the survey was the information on needed technical assistance, with a major emphasis on program development and planning. The Housing Experts Meeting is the beginning of NASMHPD's response to needs identified by the Focus Group and by the Housing Survey. This meeting will result in the production of a white paper and related technical assistance tools which will provide state mental health authorities with the needed material to keep housing and supports as key elements in public mental health systems.
Housing has been a topic of much debate and discussion within the mental health field for several years. The nation suffers from a chronic shortage of affordable and available low-income housing. This shortage complicates individual recovery from mental illness through limited access to regular, integrated housing. The shortage also complicates improving access to housing through outreach to landlords and the linkages created by case managers. The competition for existing housing stock is fierce. Public mental health systems have had to take extraordinary action to provide any access to regular, integrated housing. As this briefing paper will make clear, public mental health systems have taken successful steps in this area. However, the basic shortage of affordable housing has hampered even the most creative efforts and the situation is not improving.
Why have NASMHPD and CMHS re-directed our attention to housing at this time? Because the environment is changing. Pending housing legislation will reduce funding for low income housing, reduce rental assistance and repeal or suspend federal preferences for assisted housing. Welfare reform, threats to SSI, threats to funding for homeless assistance programs, including PATH and ACCESS, will, if approved, result in disaster for the people we serve. Even if federal changes do not occur, the powerful trend towards managed care will make dramatic changes to public mental health systems at the state level. Within the whirlwind of change, we are in danger of forgetting one basic fact: people still need a place to live. So, CMHS and NASMHPD have asked us to consider best practices in housing in this changing environment. The briefing paper presents a summary of some actions taken by state mental health authorities in the general area of housing and is a starting point for the work of the experts at the November, 1995 meeting.
The Housing Expert's meeting is structured around three state case studies. The case studies will be used to explore the full range of housing issues, as follows: (1) planning; (2) financing strategies/partnerships; (3) development, management; (4) rental assistance strategies; (5) housing and market preferences; (6) housing in a managed care environment; (7) access to supports; and (8) rights. This briefing paper presents each identified housing issue and provides related state mental health authority experiences and examples.
Executive Summary
The briefing paper examines key issues and presents examples in eight areas: (1) planning; (2) financing strategies/partnerships; (3) development, management; (4) rental assistance strategies; (5) housing and market preferences; (6) housing in a managed care environment; (7) access to supports; and (8) rights.
Planning
State mental health authorities have taken action or assisted local authorities to take action in two general planning activities. First, the HUD Consolidated Plan offers an opportunity for concerned citizens to provide input and channel resources to people who are most in need, particularly persons with serious mental illness. Successful CONPLAN strategies include provider/advocate membership on the CONPLAN committee, advocating for a "fair share" of the resources on the table, educating advocates, creating alliances and organizing the effort. A second highly successful effort is the creation of local and state strategic plans for housing for persons with mental illness. Strategic housing plans include policy development, the creation of partnerships, the dedication of resources, and setting feasible and measurable goals. Many states, including Ohio, New York, Connecticut, Virginia and others, have successfully used these planning strategies to increase the number of housing units available to persons with serious mental illness.
Financing Strategies/Partnerships
This section explores ideas and projects that have been created by blending funding from multiple sources. This can include the combination of different types of government funding: federal, state and local. This also includes blended funding strategies using public and private sources, with the Mental Health Housing Development Corporation in Ft. Worth, TX offered as an example.
Development/management
State mental health authorities have experimented with a number of ways to increase the number of affordable units available to persons with mental illness. Housing development is a challenging activity in which the state authority directly undertakes the development of more units, either alone or in partnership with public or private entities. Examples include the Robert Wood Johnson Foundation Program on Chronic Mental Illness and the South Carolina use of the Section 811 program.
Beyond development, state mental health authorities have supported or created a number of arrangements designed to improve consumer access to existing units. This can include allocating dollars for this activity directly, sponsoring or encouraging public housing authority/mental health authority partnerships, or obtaining a set-aside or other targeted funding from the housing finance agency.
Rental Assistance Strategies
The discussion of rental assistance strategies focuses on publicly funded mechanisms for supplementingthe ability of poor people to pay rent in regular housing. Most of the examples presented use federal or federal/state blended funding to create rental subsidies. The State of Ohio has one of the first statewide rental assistance programs, known as the Housing Assistance Program (HAP). This program "provides funds to local mental health entities to assist persons obtain existing rental housing of the same range and types as are available to the general public, and which are regulated by leases/rental agreements governed by Ohio landlord-tenant law" (Ohio Department of Mental Health). In 1994, 2,600 persons were assisted through HAP, with an FY94 allocation of $3.4 million. The average cost of an operating subsidy is $284 per month (statewide). Ohio has targeted assistance to persons who are homeless, persons who are being discharged from state facilities and others at risk of homelessness.
Housing and Market Preferences
For too long, public mental health systems have given either too little attention to the issue of where people live, or have given too much attention to the development of segregated, group living arrangements. It is only within the last ten years that some state mental health authorities have begun to ask consumers about their preferences for where and how they live. This section describes how to design and implement consumer preference studies, and also how to maximize the effective use of the data in planning and implementation of housing strategies.
Managed Care: The Impact on Housing and Supports
Managed care in public mental health systems is reality for many states. Most states have received, have applied for or are planning a waiver request that will allow managed care experimentation with Medicaid. The changes to public mental health systems as a result of managed care will include who is served, what services are received, how services are provided and what outcomes are considered acceptable. Other changes will include increased sophistication regarding data collection, analysis and use.
The experience of the public mental health system to date suggests that when attention and resources are focused on where people live, outcomes improve for people with serious mental illness. The concern is that this experience will be lost in the rush to manage care and costs. Effective efforts to introduce housing related outcomes will focus on data and research demonstrating that attention to where people live results in a reduced need for costly, acute care services. This section explores those issues and looks at strategies designed to preserve a focus on housing in a managed care environment
Access to Supports
Housing and related supports produce predictable, favorable outcomes for persons with serious mental illness. Positive outcomes only occur when adequate, flexible supports are readily available. Access to supports is essential to the success of any housing opportunity for persons with psychiatric disabilities. It is the responsibility of the mental health system to ensure the availability of supports that are flexible and tailored to individual need.
In recent years, persons with psychiatric disabilities have been served with activities known as "supported housing". Supported housing combines system attention to where people live with a network of supports and services. Research has demonstrated the effectiveness of supported housing activities across the nation. When mental health systems invest in supported housing, outcomes for individuals improve and the need for more expensive services decreases. Supported housing has been adopted as a strategy by many state mental health authorities including Vermont, New York, Massachusetts, Ohio and Texas.
Rights
Federal legislation provides persons with psychiatric disabilities with some protection from discrimination in housing and other areas. The federal Fair Housing Act Amendments of 1988, the Americans with Disabilities Act and section 504 of the Rehabilitation Act of 1973 together provide protection from discrimination in all areas of housing, including access to housing units, living conditions and evictions. Current law provides rights protection for specific forms of discrimination and requires reasonable accommodation for persons with disabilities. At present, there are several legislative actions that could threaten the effectiveness of current law.
I. Planning
A. Overview
The NASMHPD State of the States Housing Survey results indicate a strong need for information and technical assistance in this area. Nearly half of the respondents (23 of 47)indicated a need for information on federal programs and legislative updates, and interest in the Consolidated Plan (CONPLAN) and HUD programs in general is very high.
The Consolidated Plan is a HUD required document that presents a comprehensive picture of the need for community improvements, including low income housing, for every city and county in the nation with a population over 50,000. This presents a priceless opportunity for local advocates, providers and concerned citizens to obtain a fair share of resources for people who are most in need. The discussion of housing planning (below) focuses on this opportunity, with an examination of activity at the state and local levels that is designed to yield measurable increases in housing for persons with mental illness. Briefly, this section includes a discussion of the requirements under law for citizen participation, strategies for successful local input and the role of the state.
In addition to the HUD CONPLAN opportunity, the development of state and local housing plans is an effective technique for increasing resources. Successful planning includes community leaders, advocates, family members and consumers. The strategic plan for housing includes the development of policy, formal state level interagency agreements, available resources, including blended funding strategies, and measurable feasible goals in yearly increments.
B. Key Ideas and Examples
1. Maximizing the CONPLAN Opportunity
In HUD CONPLAN process, citizen participation at both the local and state level is the law. At the state level, service providers must be consulted during the production of the plan and public hearings must be held before and after the plan is drafted. Both state and local governments are required to create and implement a citizen participation plan that meets minimum HUD requirements. Strategies for maximizing local input and suggestions for state level activity are presented below. These strategies have been used effectively in several states (Ohio, Connecticut, Virginia and others) and are discussed here to illustrate feasible options for state activity. Strategies for successful local input are discussed below.
a) The "fair share" strategy: Local governments frequently have entrenched constituencies which historically received a share of the funds now governed by the CONPLAN. This is particularly true of Community Development Block Grants. One method for addressing this issue is to focus on ensuring that the plan development process is inclusive and fair. Planners are required to make information available to the public, and this includes information on who is writing the plan, when it is due, how much opportunity remains for significant impact on the plan, the schedule for public hearings and the process for response to comments. Advocates who adopt a fair share strategy will start by obtaining a copy of the citizen participation plan and information about committee membership, current plan status and the procedure for making complaints to HUD. The second element of the fair share strategy is information. An effective strategy is to study previous community plans and obtain an accurate picture of the past use of resources. Advocates who have current information on the housing status and the needs of the populations they represent will be more successful in arguing for new uses for those dollars. The key to this step is to obtain enough knowledge about the process, the size and historical use of the resources on the table, the needs of the community and the particular needs of persons with mental illness to argue for a reasonable and fair share of resources. The third element in the fair share strategy is the possible use of "set-asides". In this step, providers and advocates ask that percentages of specific allocations be reserved for particular groups (see Massachusetts example, page 13).
b) Learning the language: Most service providers and advocates for people with mental illness are not experienced with the housing industry and do not understand the language and the workings of this complex topic. A successful strategy is to create and/or use simple to understand training materials that teach advocates the major issues in this area. An excellent source for materials of this kind is the Low Income Housing Information Service (see the 1995 Advocates Handbook).
Training efforts which focus on consumers, family groups and service providers are necessary. The goal is to allow advocates to argue effectively for a fair share of resources. In order to do this, they need a basic understanding of the language and issues in this area. Targeted groups include self-advocacy consumer groups, the Alliance for the Mentally Ill, Mental Health Association chapters and others. Materials should include a menu of options for CONPLAN advocacy.
c) Partnerships. Partnerships are essential in the fair share strategy. Low income housing advocates are natural allies and frequently can be persuaded of the wisdom of a fair share of resources for people with disabilities. Other natural allies include people with physical and mental disabilities and elderly people and their advocates.
d) Organize the effort: The membership of the local CONPLAN committee is a fertile area for action. The participation of some service providers is assured by the law, but working for a good distribution of service providers is essential. Consumers and family members should be encouraged to serve on the committee. A second area for organization is getting the word out! Mailings, posters, public forums, letters to the editor are all ways of informing people about opportunities to participate. Good information sharing and publicity activity will help maximize the opportunity offered by public hearings.
e) State Activity: All of the actions described above for local activity are applicable to the state level. This includes participation on the state planning committee charged with creating the draft document and the facilitation and encouragement of participation by consumers and family members on the committee. The goal of state activity is to increase the number of housing units available for persons with mental illness through inclusion, a fair share and actual set-asides.
The state mental health authority has an equally important role in improving the effectiveness of advocacy organizations through the provision of information, training and encouragement. Specifically, the state mental health authority can develop training materials for use at the local level that address the issues of language, fair housing, details regarding allowable activities, and ideas for accessing the local process.
2. Strategic Planning for Housing
a) Policy Development: An essential activity at the state level is the development, dissemination and implementation of an official state mental health authority policy. Effective policy articulates the values and assumptions that form the basis of and are reflected in the remainder of the policy, including issues of need, choice, integration, services and supports and resources. The policy should include an action plan with measurable goals and objectives. The inclusion of consumers, family members, service providers, the state housing finance agency and other relevant state agencies is essential for policy development. A useful strategy in policy development is to set well defined boundaries in the committee's charge, that is, if the decision has been made to encourage supported housing and to discourage congregate living arrangements, this information should be communicated from the leadership to the committee. Another useful strategy is to bring in an external facilitator that can provide information on other states' experiences and add legitimacy to the project. These strategies have been used successfully in Virginia and Missouri, among others (see Commonwealth of Virginia, 1992, for example).
b) Partnerships. The development of a strategic plan for housing is also an opportunity to create partnerships among consumers, families, providers and funding agencies. The development of a shared vision and the inclusion of many stakeholders creates enthusiasm for action. One result for many states is the development of new state mental health authority/state housing finance agency agreements. Thebest practice here is to formalize the partnerships through Memoranda of Agreement/Understanding. These documents should reiterate values and assumptions, interagency action plans and, if possible, the allocation of resources to the partnership.
c) Designated Resources. To the maximum extent possible, interested partners should be persuaded to bring meaningful resources to the table. Typically, the largest contributors to housing partnerships are the state mental health authority and the state housing finance agency. Other partners can contribute funds or in-kind resources to the project.
d) Feasible goals. For states, feasible goals might include the reduction of the number of placements available in congregate settings and a matching increase in the number of regular, integrated housing units available. A second goal might be the inclusion of the housing policy and a requirement for local housing activity in the contract between the state authority and the local authorities/providers. Other goals include targets for local authorities regarding number of units newly available to or added to local system, participation in local planning processes and measured increases in numbers of people served.
C. Current Status/Legislative Update
The Department of Housing and Urban Development has been the subject of much discussion during this legislative session. At present, the House and Senate have drafted competing versions of HUD appropriations bills which have been sent to Conference Committee. Although no final decisions have been made, the outlook is not good. Cuts in the Section 8 program, reduced funding for homeless housing programs, changes to public housing programs and a weakening of enforcement of fair housing provision are among the proposed changes. (See Rental Assistance, Current Status, p. 15 and Rights, Current Status, p.24 for more detail).
II. Financing Strategies/Partnerships
A. Overview
State mental health authorities have experimented with a number of ways to create partnerships and financing strategies that will measurably increase the number of housing units available to persons with serious mental illness. The NASMHPD State of the States Housing Survey indicated an interest from states in information on these partnerships, blended funding strategies and other financing methods.
B. Key ideas and examples
1. State funding collaborations.
Successful partnerships have been formed between state mental health authorities and state housingfinancing agencies. In Texas, the state mental health authority and the Department of Housing and Community Affairs have plans to combine funding to create a special housing trust fund for persons with mental illness and mental retardation. Allowable uses of the funds will include opportunities for home ownership, rental subsidies, support services (MHA funds only), and match funds for local housing development strategies that result in scattered site, integrated housing. Local matching dollars will be required. Source of the funds contributed by the state mental health authority is revenue from the sale or lease of state facility land. Source of funds contributed by the Housing and Community Affairs department are federal HOME funds and state general revenue Housing Trust Fund dollars. The expectation is for over 1.5 million dollars to be made available next fiscal year.
2. Public/Private Partnerships
State and local mental health authorities have experimented with various strategies in partnership to increase housing units. A good example of public/private partnerships is the Mental Health Housing Development Corporation in Ft. Worth TX. This corporation created a partnership package with funds from local banks and the Enterprise Foundation, Section 8 assistance through the Ft. Worth Housing Authority and service agreements with the local mental health authority that enabled the purchase of a 30 unit apartment complex. Fifty percent of the units are occupied by persons with serious mental illness, and the remaining units are leased to the general public. This corporation currently has over 100 units under development. The corporation also assists the local mental health authority with applications for funding and is a partner in the Ft. Worth Shelter Plus Care project and the ACCESS project. The creation of an independent private non-profit housing development corporation is an excellent financing strategy for local and state mental health authorities.
C. Current Status
Partnerships and blended funding strategies are excellent methods for combining targeted funding, expertise and resources from multiple sources to achieve a result that is greater than any one source could achieve alone. However, the status of HUD programs is presently uncertain. Overall funding is likely to be reduced. This is unfortunate because HOME and other HUD programs has allowed the development of successful projects. Without this source of funds, partnerships and blended funding strategies will become a greater challenge.
III. Development/management
A. Overview
The NASMHPD State of the States Housing Survey shows a strong interest in methods of housing development (15 of 47) and in the management of housing programs (21 of 47).
The overall goal of our interest in housing is to increase the number of units occupied by persons with serious mental illness. There are only three general methods of achieving the goal: increase the supply (housing development), increase access to existing housing or create rental assistance strategies that make existing housing stock more affordable. Activities described in this section include methods designed toincrease the supply and increase access to existing housing. Rental assistance strategies are discussed in the next section.
B. Key Ideas and Examples
1. Housing Development
One of the most challenging areas for state mental health authority housing staff is mastery of the details of housing development - "making the numbers work". Fortunately, there are many resources and successful examples. The public mental health system and others have experimented with several methods of housing development, including direct ownership and control by mental health systems, the creation of special purpose housing development corporations and consumer controlled housing development initiatives.
a) Direct ownership and control: The Robert Wood Johnson Foundation Program on Chronic Mental Illness required grantees to develop housing units in their communities. This requirement for housing development in combination with a requirement for the development of a single local authority structure resulted in the development of hundreds of units nationwide under the direct ownership and control of public mental health systems. One advantage of direct ownership and control is undisputed access to housing units for people with mental illness. Financing strategies include traditional mortgage arrangements with lenders and access to the HUD Section 811 program. One disadvantage of direct ownership and control of units is the financial and time burden associated with property management. Another disadvantage is the inherent role conflict between the mental health system as both service provider and landlord. If case managers are collecting the rent, where do consumers go for help when they can't make the payment?
b) HUD Section 811 program. The HUD Section 811 program provides funds for construction or acquisition/rehabilitation of structures and project based rental assistance for the purpose of creating housing for persons with disabilities. A good example of a state mental health authority using the 811 program as a housing development strategy is South Carolina. This program has been used to develop over 200 units of housing. The state mental health authority provides technical assistance, linkage to consultants, assistance with site location and control and matching funds to local private non- profits that apply for funds. The advantages of using this program include the rich mix of acquisition dollars and rent support. Even with the inclusion of local funds for predevelopment costs and other expenses, the 811 program is the most financially feasible program available. Disadvantages include the long start up time (best case = three years) and HUD bureaucratic red tape.
c) Special purpose housing development corporations. The Corporation for SupportiveHousing is an excellent example of a special purpose housing development corporation. The advantages of special purpose housing development corporations include the concentration of expertise and resources in this area and role clarity with regard to housing.
2. Access to existing housing units
A second strategy to increase the number of housing units available and affordable for people with mental illness is to increase access to existing units. Most state mental health authority supported housing programs fall into this category. Programs are typically designed to improve access through prior agreements with landlords or through formal agreements with housing developers or housing authorities. Programs also typically include some mechanism for making units affordable, usually a rental subsidy. Finally, successful efforts include a firm commitment of supports and services for residents. Examples include the Collaborative Support Program of New Jersey, a consumer controlled housing initiative and PHA/MHA partnerships.
a) Consumer controlled initiatives. An excellent example is the Collaborative Support Program (CSP) of New Jersey. The CSP Board of Directors has a majority of mental health consumers. The organization leases over 50 different scattered sites, using a mix of apartments, condominiums and single family homes. Consumers choose units from the general market or from within the CSP inventory. Consumers pay 30% of their income in rent and CSP provides a subsidy for the remainder. The organization also pays utilities and provides insurance. Choice is preserved re: roommates and location of housing. The advantages of consumer controlled housing development initiatives include genuine choice for residents and a real separation between access to housing and access to supports.
.
b) Public Housing Authority/Mental Health Authority partnerships. Several years ago, the Center for Mental Health Services published a "Blueprint of a Cooperative Agreement" for use by PHAs and MHAs. This document has been used many times during the creation of partnerships.
The Shelter Plus Care program has been a flexible and valuable resource and a natural fit for PHA/MHA partnerships. The program provides applicants with a choice between four types of rental assistance (tenant based, project based, sponsor based or Single Room Occupancy) and requires a dollar for dollar services match. The target population is literally homeless persons with disabilities, including persons with mental illness. Eligible applicants include states, units of general local government, public housing agencies and Indian tribes. Many successful applications have created a partnership structure among the local housing authority and various service providers. For example, in San Antonio, TX, the San Antonio Housing Authority is in partnership with the Center for Health Care Services (San Antonio's mental health authority) to provide 90 units of housing and related services to literally homeless persons with serious mental illness. The San Antonio PATH program funds were pledged as part of the service match.
c) Massachusetts. The Massachusetts Housing Finance Agency sets aside 3% of all units for people with mental illnesses. This set aside applies to newly funded and refinanced units. This agreement has resulted in over 2,000 units becoming available for persons with mental illness. The project is governed by a Memorandum of Understanding between the Massachusetts Housing Finance Agency, the State Department of Mental Health and the State Department of Mental Retardation which commits the agencies to a partnership to create and support independent housing and to "plan and carry out suchaccommodations and supportive services as may be necessary to ensure the successful integration of consumers into permanent housing" (MOU).
C. Current Status
All programs designed to increase the number of available units or to increase access to units are threatened by the general environment of reduced funding and may be overlooked as states move into managed care.
IV. Rental Assistance Strategies
A. Overview
The NASMHPD State of the States Housing Survey shows a strong interest in the development of rental assistance programs (19 states) and managing housing programs (21 states). The provision of rental assistance is a successful strategy for persons with serious mental illness. Rental subsidies allow consumer choice in housing, make it possible for people to live alone or with friends or loved ones of their choice, and promote community integration. Sources of rental assistance include the federal Section 8 program, tenant-based rental assistance through HOME, Shelter Plus Care and other programs, and state general revenue rental assistance funds.
Services and supports are essential to the success of rental assistance strategies (see Access to Supports, p.20). In addition to the provision of supports and services, the mental health authority has two functions with regard to rental assistance strategies. At the system level, the mental health authority creates partnerships and improves access to resources which make the housing affordable. At the service level, the case manager plays in indispensable role in linking people to housing assistance. Often this includes assisting people with the application process and assisting people in locating and obtaining the housing itself. Without these activities, access to rental assistance would be meaningless.
B. Key Ideas and Examples
1. Federal Rental Assistance
The most common form of rental assistance is the federal Section 8 program. This program is targeted to low income persons and provides a subsidy to individuals and families that pays the difference between 30% of income and the local fair market rent. This program is typically operated by public housing authorities and city/county governments. Most communities have waiting lists for the Section 8 program, with some waiting times in excess of two years. Some communities have closed their waiting lists, not allowing poor people to even put their name on a list. The federal government has established a number of preference categories that will help people move to the top of the list, including homelessness, disability and severe cost burden (payment of 50% or more of income towards housing). Because this resource is in such short supply, the practical application of preferences means that if an individual is not in a preference category, he or she will never get to the top of the list. While this is unfortunate for many low income persons, the federal preferences have helped to make this resource available to persons with mental illness in some communities.
The tenant based rental assistance provisions in HOME and Shelter Plus Care allow grantees to provide subsidies to low income and homeless persons using Section 8 as a model.
2. State general revenue programs.
Several states, including Ohio, New York, and Vermont, have created rental subsidy programs using state general revenue dollars. In some cases, these funds are mental health service dollars and in other cases the programs are operated with blended funding from the housing finance agency and service agencies. In all cases, general revenue funded programs are intended to bridge the gap between no assistance and the time when federal assistance becomes available.
The State of Ohio has one of the first rental assistance programs, known as the Housing Assistance Program (HAP). This program "provides funds to local mental health entities to assist persons obtain existing rental housing of the same range and types as are available to the general public, and which are regulated by leases/rental agreements governed by Ohio landlord-tenant law" (Ohio Department of Mental Health). In 1994, 2,600 persons were assisted through HAP, with an FY94 allocation of $3.4 million. The state FY96 allocation for this activity is $4.4 million. The average cost of an operating subsidy is $284 per month (statewide). Ohio has targeted assistance to persons who are homeless, persons who are being discharged from state facilities and others at risk of homelessness.
In implementation and practice, HAP has encountered some barriers. The relationship between the mental health system and public housing authorities may have conflict, particularly around the issues of preferences and waiting lists. Specifically, some housing authorities remove mental health consumers from the preference category because the receipt of HAP funds reduces their housing cost burden. In communities where the waiting list is closed, partnership with the housing authority becomes more difficult. Even where good working relationships exist, occasional conflict can occur over reasonable accommodation and provision of support services. For example, the mental health system may want the PHA to accept an individual with a poor rental history, using reasonable accommodation as a rationale. The PHA may be unwilling to do so, partly from a fear the mental health provider will not make good on promises to provide adequate supports, especially in a crisis. The solution to these difficulties includes solid working agreements with dedicated resources from both partners and an ongoing commitment to making the partnership effective through good communication.
C. Current Status
The FY96 HUD Appropriations bills (House and Senate versions) contain reductions in funding and changes to regulations that will have a negative impact on federal rental assistance programs. As federal assistance becomes more limited, the strain on state general revenue programs will increase.
Although the FY96 HUD Appropriations bill is in conference committee and has not been finalized, there is sufficient agreement between the House and Senate versions to predict that federal rental assistance will be reduced. Some of the more alarming proposed provisions include: repeal or suspension of federal preferences; no new Section 8 vouchers/certificates in FY96; certificates/vouchers turned in cannot be reissued for 6 months; increased tenant rent payments; fair market rents set at the 40th percentile. The result will be reduced opportunity to obtain federal rental assistance and increased rents combined with reduced subsidy amounts for individuals who are already receiving assistance.
V. Housing and Market Preferences
A. Overview
The NASMHPD State of the States Housing Survey shows a healthy interest in consumer preferences and the use of this information (21 of 47 states sampled). Much of the information on consumer/provider preferences is widely available. This section discusses methods of data collection and provides examples of good uses of data to guide state housing policy and actions.
For too long, public mental health systems have given either too little attention to the issue of where people live, or have given too much attention to the development of segregated, group living arrangements. It is only within the last ten years that some state mental health authorities have begun to ask consumers about their preferences for where and how they live. The Center for Community Change through Housing and Support has taken the lead on developing consumer preference survey methodologies. This section briefly describes how to design and implement consumer preference studies, and also how to maximize the effective use of the data in planning and implementation of housing strategies.
B. Key Ideas and Examples
1. Consumer preferences: Asking the questions.
Designing the survey: The first step in seeking information on consumer preferences is to assemble the stakeholders. Stakeholders include consumers and family members, direct service providers, administrators, and community leaders. Effective use of such a stakeholders' group includes providing a clear charge to the group, with definite goals and products. The stakeholders group needs access to existing surveys and the freedom to adjust those surveys to local need. Stakeholders make decisions about who is to be asked, what they will be asked, and how the questions will be asked (Tanzman, 1993). The literature suggests that the most effective method of obtaining information is the use of peer interviewers.
2. Typical survey results.
Tanzman (1993) compares results from 26 consumer preference surveys. Overwhelmingly, "the most preferred housing arrangement in every study was independent living in a house or apartment". Also, consumers surveyed preferred to live alone or with a spouse or romantic partner of their choosing. It is interesting to note that the need for support services is acknowledged through a preference for 24 hour availability of staff and the need for material supports in the areas of income, benefits, deposits, telephones and transportation. The consistency of these results should set a policy direction of choice as a guiding principle that is not subject to debate.
3. Using the Survey Results
As Carling (1994) points out, valid consumer preference data has numerous valuable uses. At a minimum, consumer preference data should guide the development of policy and planning for the state mental health authority. This information should be used to guide allocations of housing and support services dollars and is particularly useful in local and state CONPLAN activities.
The information is useful in establishing alliances with other low income housing advocacy groups, because housing concerns for people with special needs ARE NOT DIFFERENT from other Americans. Having data to support this point is essential in forging alliances.
C. Current Status
As most state mental health authorities move into managed care, there is a risk that the focus on consumer involvement in decision making will be lost. However, the work that has been done in the area of consumer preferences and the evaluation of outcomes for individuals in supported housing will be useful tools in the new environment. Managed care is data driven. Preference and outcome data will be essential in preserving housing in the years to come.
VI. Managed Care: The Impact on Housing and Supports
A. Overview
The NASMHPD State of the States Housing Survey did not address the issue of managed care, but over half of the states are planning, have applied for or have been granted some form of waiver that will allow experimentation with forms of managed care. Congress is moving closer to a block grant for Medicaid, which will allow states to create managed care systems without the necessity of completing the waiver process. The changes to public mental health systems as a result of managed care could include who is served, what services are received, how services are provided and what outcomes are considered acceptable. Other changes will include increased sophistication regarding data collection, analysis and use.
The experience of the public mental health system to date suggests that when attention and resources are focused on where people live, outcomes improve for people with serious mental illness. The concern is that this experience will be lost in the rush to manage care and costs. Effective efforts to introduce housing related outcomes will focus on data and research demonstrating that attention to where people live results in a reduced need for costly, acute care services. This section explores those issues and looks at strategies designed to preserve a focus on housing in a managed care environment.
B. Key Ideas and Examples
The overall strategy is to understand and use managed care concepts to preserve housing as a legitimate area of activity and interest for public mental health systems. The focus in this section is on the structure of the public mental health service array, the benefit package for people with serious mental illness, decisions about who is served, how they are served, and the range of acceptable outcomes. The general direction of these efforts is to include housing and supports in the array of services, make explicit distinctions between acute and long term care needs (benefits packages), make sure that access to long term services is limited to people who have serious mental illness, design minimum outcomes to include community tenure and community integration, and explicitly define the best practices to achieve these outcomes.
1. Service Array.
Most fully developed managed care systems have been in the area of general health and include such common examples as Health Maintenance Organizations (HMOs). In these examples, emphasis has been on acute care episodes. The danger in a blanket application of general health managed care structures to serious mental illness is the loss of long term care and support options. In an acute care environment, it is hard to argue that housing and ongoing support services are "medically necessary". Research on long term supports and services indicates that the use of supported housing and other technologies improves outcomes for people and reduces the need for medically necessary services. Therefore, it is essential that the idea of the need for long term services and supports, including a focus on housing, be introduced as early as possible in the design of managed care. Services should be explicitly designed to handle a high volume of cases in an acute care setting, with a clear path for persons with serious and persistent mental illness to move into a long term care structure that allows system interest and support in many areas, including housing and jobs. (Wanser, 1995)
2. Benefits Package.
Another, related strategy is to explicitly design a benefits package available to persons with serious mental illness that includes levels of care. Most of the community support programs, including supported housing and supported employment, belong in the benefits package. Assignment to a level of care in the long term benefits package is linked to a reliable and valid standardized assessment that can be used to obtain and keep eligibility for the level of care. Inclusion of housing and related support services in the benefits package creates a system in which attention to housing is reimbursable and related outcomes can be defined and measured. (Wanser, 1995).
3. Gatekeeping.
Who is eligible to obtain public mental health services, and, within that group, who is eligible for long term services and supports? A standardized, uniform assessment package is an effective gatekeeping tool. In Texas, the Uniform Assessment Project is designing a standard package that determines the presence or absence of serious mental illness as well as a measure of functioning. The state mental health authority has defined a priority population determined by the factors of diagnosis and functioning. Public mental health systems define eligible populations so that long term support services, including housing and related supports, are available only to persons with serious and persistent mental illness.
4. Utilization Review/Utilization Management.
As described above, state mental health authorities define eligible populations, the inclusion/exclusion criteria for eligibility and prescribe ongoing re-certifications of eligibility. Access to long term services and supports is restricted to persons with serious and persistent mental illness. Periodic review of who is receiving services and the level of service received, as well as an assessment of the "fit" between need and services received, allows systems to limit expenditures and maintain good outcomes. Thorough utilization review and effective utilization management are the sources of much of the savings associated with managed care.
The development of levels of care that are clearly linked to assessed need is an important aspect of utilization management. Levels of care within the long term benefits package include various services and supports including housing. An effective strategy for including housing and supports within the levels of care is an emphasis on the connection between supported housing and the reduced need for medically necessary services. Individual eligibility for housing services will be linked to different levels and intensities of service, and ongoing assessment of eligibility and assessment of service utilization will ensure that people with serious mental illness receive services at the appropriate level.
5. Outcomes.
In a managed care environment, state authorities will purchase outcomes for a specified number of people with serious mental illness. An effective strategy for the inclusion of housing and supports is for the state authority to identify required outcomes that can be achieved only through the delivery of housing and support services. This can be accomplished through careful definition of outcomes, a mechanism for comparing outcomes, and enforcement of sanctions for non-performance.
Common outcome measures include satisfaction and quality of life. There are a number of standardized measures (Lehman, for example) that can be used. The state authority reviews available measures and selects a set of measures for statewide use. This allows comparisons among local authorities in the achievement of outcomes. Effective development of outcome measures always includes consumer and family participation.
Beyond satisfaction and quality of life measures, the state authority designs and implements measures of community tenure and community integration. Community tenure measures include information on where people live, how many moves they have made, how many days have they spent in any type of institution (jail, local hospital, state hospital), time homeless, and comparison of the current year's community tenure with the previous year's community tenure. Community integration outcomes include the degree to which consumers use generic community services (libraries, transportation, adult education) and the degree to which they have friends and supports outside of the public mental health system. Other measured outcomes can include physical health, psychiatric stability and symptom management. The inclusion of community tenure and community integration outcome measures is an effective strategy because good outcomes are difficult to obtain unless the mental health system is assisting people with housing and supports.
For all outcomes measures, the methods of collection include widespread survey distribution and random sampling of selected service recipients. With sampled individuals, a best practice is to interview consumers, family members and staff. Use of peer interviewers is recommended.
6. Best Practices.
Where there is research to support the link between level and type of service and positive outcomes, the state authority may define and require "best practices" services. The rationale for the prescription of best practice services is the reduction in the need for medically necessary services. Best practices services and supports include supported housing, assertive community treatment and supported employment.
7. Network Management
Network management includes activities undertaken by the state or local authority to manage the activities of a network of providers. Functions include information sharing and training for providers, assurance that training was obtained, compliance monitoring, updating and renewing of credentials, provider profiling, information management, grievance procedures, etc. There is another set of activities commonly grouped with network management that are best described as network development. These activities include developing processes for contracting with providers, defining the range of providers needed and the nature of the relationship, projecting need with regard to the network capacity and provider availability, and standards development. (Wanser, 1995).
The state authority sets best practice guidelines, defines conditions of participation for local authorities and providers, and provides technical assistance to local authorities as they build local networks of providers. Network development and network management are important opportunities to build housing and supports into the system structures. For example, contracting could include purchasing outcomes that require the provision of housing and support services.
C. Current Status
Several states have applied for and received 1115 Demonstration waivers that allow drastic modifications to the state Medicaid system. Most of the 1115 waivers have been used to demonstrate managed care in some form, usually with physical health care for the AFDC population. Tennessee is one example of a state system that included mental health services in the managed care system.
The 104th Legislature is considering various options to block grant Medicaid. When this occurs, the need for waivers will disappear and states will be free to create systems for managing care without meaningful federal oversight.
VII. Access to Supports
A. Overview
The NASMHPD State of the States Housing Survey showed interest in the linkage between housing and supports (13 of 47 respondents). Nineteen states reported sufficient competency in this area to provide technical assistance to others.
Housing and related supports for persons with mental illness have a future in the managed care environment only to the extent that they provide predictable, favorable outcomes for persons with serious mental illness. Positive outcomes only occur when adequate, flexible supports are readily available. Access to supports is essential to the success of any housing opportunity for persons with psychiatric disabilities. It is the responsibility of the mental health system to ensure the availability of supports that are flexible and tailored to individual need.
In recent years, persons with psychiatric disabilities have been served with activities known as "supported housing". Supported housing combines system attention to where people live with a network of supportsand services. Research has demonstrated the effectiveness of supported housing activities across the nation. When mental health systems invest in supported housing, outcomes for individuals improve and the need for more expensive services decreases. Supported housing has been adopted as a strategy by many state mental health authorities including Vermont, New York, Massachusetts, Ohio and Texas. For these reasons, supported housing has been selected as the example for inclusion in this section. Other types of assistance related to where people live (congregated settings, roommate matching, case management advocacy with landlords, etc) have not been included here.
Specifically, this section explores issues and successful practices in supported housing, including the link between housing and supports, the principles basic to good supports and examples. Material in this section has been drawn from the Connecticut experience.
B. Key Ideas and Examples
1. The link between housing and supports.
The link between housing and supports has been controversial. The "housing-as-housing" group holds that housing is a basic human need, people with mental illness have a right to live where and how they choose, and any requirement for compliance with treatment as a condition of the housing is inappropriate. On the other side is the group that argues that supports are necessary and desirable for individuals with serious mental illness and that people with mental illness do not always recognize the need for supports and services. This group advocates for some linkage between compliance with treatment and retention of housing.
Successful supported housing efforts formally disconnect the provision of housing assistance from the provision of supports and services. This means that a person's housing is not dependent upon compliance with treatment. This separation is absolutely essential - it is what makes the difference between true supported housing and less successful system efforts to provide a place to live.
However, in successful examples of supported housing, supports and services tied to housing assistance is an absolute requirement for the system There is an important distinction here. Are supports and services required from the individual perspective? No. Are supports and services required to be available? Yes, the mental health system is required to provide adequate supports and services for each individual. This distinction is best made in the area of contracts, budgets, and procedure. An effective mechanisms for achieving this goal is the inclusion of requirements in contracts and budgets that show the availability of the supports and services. Procedures for operation can be required to demonstrate that supports and services are provided only when chosen by the individual.
2. Principles of support
The provision of supports and services to persons with mental illness in regular, integrated housing that has been chosen by the individual is a true paradigm shift for most public mental health systems. In designing these supports and services, decision makers recognize that the goal of these supports is for individuals to choose, get and keep the housing of their choice. The focus on housing requires that mental health providers reach beyond the boundaries of the traditional mental health system and engage in service partnerships with substance abuse providers and health providers. Real community living involves a reliance on natural networks of family, friends and generic community services (education, transportation, etc). Working partnerships are required at the agency level and good case management work is needed at the individual level. Other supports or services that are crucial to successful supported housing include in-home skills training, crisis response and crisis support services, peer support and employment services.
This section of the briefing paper has focused on supported housing examples, but the principles of support apply equally well to any setting. Many people with mental illness live in congregated settings, with families or with roommates. Regardless of the setting, the best practice in supports and services is activities guided by the principles of support outlined here.
3. The Connecticut Example
The Connecticut Department of Mental Health Housing and Homelessness Policy is an excellent state example of the incorporation of principles into official department policy and action. This document explicitly separates housing from compliance with treatment/acceptance of services. The Connecticut policy also separates housing from residential services in the service array and defines housing as "a leased or owned living arrangement in the individual's own name that is independent of service provision" (page 7). This definition facilitates the use of regular, integrated housing.
The policy includes action steps which define department activity. These include the development of partnerships, identification of barriers to housing, mental health system financing and other support for housing initiatives. In a separate section, the policy sets out action steps related to support services, including: inclusion of consumers and family members in services planning processes; a minimum array of services available to persons receiving housing assistance; linkage to substance abuse, education, entitlement and employment services; coordination with the criminal justice system; required outreach services; and, improved crisis services and services in natural settings.
C. Current Status
The policies and procedures which are the organizational basis for supported housing activities will continue to be under the direct control of state mental health authorities. Even under managed care systems, housing and the related support services can be preserved through careful definitions of service recipients, levels of care and related benefits packages and detailed outcomes. See Section VI, Managed Care for more detail.
VIII. Rights
A. Overview
The NASMHPD State of the States Housing Survey reveals that 16 states need and want information on fair housing issues. Recent attacks on protections from discrimination make this information timely and important.
Federal legislation provides persons with psychiatric disabilities with some protection from discrimination in housing and other areas. The federal Fair Housing Act Amendments of 1988, the Americans with Disabilities Act and section 504 of the Rehabilitation Act of 1973 together provide protection from discrimination in all areas of housing, including access to housing units, living conditions and evictions.
B. Key Ideas and Examples
1. Fair Housing Amendments Act of 1988
This legislation prohibits all forms of housing discrimination against persons with psychiatric disabilities. Landlords may not refuse to lease units to persons because of their disability, and they may not place special conditions on the lease based on a person's disability. Once an individual has moved in to a unit, a landlord may not require special conditions or behaviors from the tenant. Also, persons with psychiatric disabilities may be evicted only for violations of a standard lease. (See box). An important provision in the Fair Housing Act is the concept of reasonable accommodation. This requires landlords to change standard practices in order to allow a person with psychiatric disabilities to live in the housing unit. Some consumers do not have rental histories or have poor rental histories. Landlords can be asked to allow consumers to demonstrate their potential as a good tenant in non-ordinary ways. For example, consumers may be able to prove stable tenancy in congregate settings or demonstrate that adequate support services are available.
2. Section 504 of the Rehabilitation Act of 1973
This legislation prohibits various forms of discrimination in housing that is assisted with federal funds. It is similar to the Fair Housing Act in that assisted housing landlords may not refuse to rent or place special conditions on the rental or tenancy of people with psychiatric disabilities.
3. Americans with Disabilities Act
Although the ADA does not deal explicitly with housing, the Act is useful in prohibiting discriminatory practices in services provided by state and local government entities.
4. Reasonable accommodation
Both the Americans with Disabilities Act and the Fair Housing Amendments Act provide for reasonable accommodation. Reasonable accommodation requires landlords, employers and others to avoid discrimination against people with disabilities through changes to admission/eligibility/hiring practices, modifications to the living or working environment to allow success and alterations of eviction or firing criteria. A summary of representative cases has been provided by the Bazelon Center for Mental Health Law (attached).
C. Current Status
Current law provides rights protection for specific forms of discrimination and requires reasonable accommodation for persons with disabilities. At present, there are several legislative actions that could threaten the effectiveness of current law.
The Faircloth bill would change the Fair Housing Act to allow communities to preserve "single family" neighborhoods. This would have the effect of permitting discrimination against multiple unrelated adults residing in neighborhoods (group homes, cooperative living arrangements, etc). The Senate HUD-VA appropriations bill has language that protects community protestors from action under the Fair Housing Act as long as their protest is "otherwise legal". The House Appropriations bill would prevent HUD from investigating and prosecuting property insurance discrimination. Finally, the Senate HUD-VA appropriations bill moves the HUD Office of Fair Housing and Equal Opportunity to the Department of Justice. This is seen as a blow to enforcement of the Act because the Department of Justice lacks historical interest or expertise in these cases, lacks resources and would not emphasize voluntary compliance measures or education and conciliation activities.
(Source: Bazelon Center for Mental Health Law)
Sources
Anthony, W. A. & Wolkon, G.H. (Eds). (1990). Special Issue: Supported Housing: New Approa ches to Reside ntial Service s. Psychosocial Rehabil itation Journal, Volume 13, Numbe r 4.
Brach, D. (1995). Designing Capitation Projects for Persons with Severe Mental Illness: A Policy Guide for State and Local Officials. Technical Assistance Collaborative.
Carling, P. (1995). Return to Community: Building Support Systems for People with Psychiatric Disabilities. NY: The Guilford Press.
Connecticut Connections. (1994). Connecticut Department of Mental Health, 90 Washington Street, Hartford, CT, 06106.
Finance Options and Delivery Strategies for Persons Requiring Mental Health, Mental Retardation and Substance Abuse Services, (1992), Commonwealth of Virginia, Department of Mental Health, Mental Retardation and Substance Abuse Services, P.O. Box 1797, Richmond, VA 23214.
Freeman, M.A., Trabin, T. (1994). Managed Behavioral Healthcare: History, Models, Key Issues and Future Course. U.S. Center for Mental Health Services.
Housing and Homelessness Policy. (1995). Connecticut Department of Mental Health. 90 Washin gton Street, Hartfor d, CT, 06106.
Housing Assistance Program, Ohio Department of Mental Health, Office of Housing and System Development, 30 East Broad Street, Columbus, Ohio, 43266-0414.
Legislative Alert (July, October, 1995), Bazelon Center for Mental Health Law, 1101 Fifteenth Street NW, #1212, Washington, D.C., 20005-5002.
Legislative Update, (October, 1995), National Housing Law Project, 2201 Broadway, Suite 815, Oakland, CA 94612.
Monack, D.R. (1995). Medicaid and Managed Care: Opportunities for Innovative Service Delivery to Vulnerable Populations. Behavioral Healthcare Tomorrow, Volume 4, Number 2.
National Association of State Mental Health Program Directors. State PATH Contact Annual Meeting: The Second Generation of PATH. Meeting Proceedings. (1994). Center for Mental Health Services, U.S. Department of Health and Human Services, Rockville, MD.
National Low Income Housing Coalition. (1995). The 1995 Advocate's Resource Handbook. 1012 14th Street, NW, 12th floor, Washington, D.C. 20005.
Tanzman, B. (1993). An Overview of Surveys of Mental Health Consumers' Preferences for Housing and Support Services. Hospital and Community Psychiatry, 44:450-455.
Wanser, Dave R., Ph.D., (1995), Managed Care Workplans, internal working document, Texas Department of Mental Health and Mental Retardation, P.O. Box 12668, Austin, TX, 78711- 2668.